Here is my answer to the question Why do so many liberals still seem to think Obamacare is a success? on Quora:

All the well-voted answers are good ones.

I’ll just add a bit more for the purpose of clarity and perspective.

Health care in the U.S. is an insurance business. That means it is mostly B2B (business to business), not B2C (business to consumer). As individuals and families, we may tend on the whole to pay a portion of our largest medical expenses (doctors, hospitals, clinics, drugs), but most health care costs are paid by employers. And they are paid to insurance companies. While we should be stakeholders in this discussion, we are not.

There are only two paths around the current system, neither of which the U.S. has been willing to take.

One starts with the assumption that health care is a right and not a privilege, and to have the government manage the whole thing, to control costs, harmonize technologies and maximize accountability to the individuals who receive care. This includes “single payer,” and is what most developed countries do.

The other starts with the assumption that health care is not a right, and to make the system, as far as possible, into a B2C one, in which everybody is on their own and insurance is available to individuals in large risk pools of their own making, rather than being tied to employers. This is more consistent with the direction the world is going, with more people both independent and self-employed.

The elephant in both rooms is risk calculations based on big data about every individual. When risk data (including DNA) about individuals can be fully (or sufficiently) known by insurance companies and health care providers, it will be possible for both to guess rather well what the forward costs of care for those individuals will be. There are no easy answers to what comes next, who should be responsible for what, or what the institutional frameworks should be. The one clear thing is that none of the existing or current imagined systems can fully deal with it. And that all political positions, especially those sustained by habit, loyalty and emotion, will mislead discussions.